Present PPT will cover national immunization schedule along-with vaccine safe use and its waste disposal

1. National Immunization Schedule
Dr. Seema Bansal

2. Presentation outline
 Background and overview of Vaccination and
Immunization
 National Immunization Schedule (Jan. 2011)
 Vaccines and Cold Chain
 Safe injections, waste disposal
 AEFIs
 Desirable vaccines

3. WHO
“The two public health interventions
that have had the greatest impact on
the worlds health are
clean water and vaccines”

4. History Of Vaccination
 1796 -Jenner – cowpox
 1885 - Pasteur – cholera, diphtheria, chickenpox,
rabies
 1911 - first typhoid vaccine
 1927 - first tetanus vaccine
 1931 - Calmette & Guerin – first crude BCG
 1936 - influenza
Modern era of vaccination
 1940 - diphtheria national programme in UK
 1950’s - polio, pertussis, modern BCG
 1960’s - measles, mumps & rubella, modern
tetanus
 1980’s - H. Influenzae B (Hib)
 2000’s - Meningitis C, Human papilloma virus
(HPV)

5. Terminology
 Vaccination: the process of administering a
vaccine
 Immunisation: the process of inducing immunity
to disease
 Immunity is usually acquired naturally, but can
be induced by vaccination

6. Why immunise?
6
 To prevent or protect
against serious disease
 To eliminate a particular
disease from a defined
population
 To eradicate a disease
entirely e.g. smallpox

7.  However it is not possible to eradicate all vaccine-
preventable diseases:
 Asymptomatic carriage
 Mutating organisms e.g. influenza
 Animal reservoirs e.g. SARS, avian influenza
 Environmental reservoirs e.g. tetanus
 Global travel/mass immigration

8. 8
Vaccine preventable diseases
(bacterial)
 Diptheria
 Haemophilus influenzae B (Hib)
 Meningococcal (meningitis)
 Pneumococcal disease
 Tetanus
 Tuberculosis
 Whooping cough (pertussis)

9. 9
Vaccine preventable diseases
(viral)
 Chickenpox
 ‘flu
 Measles
 Mumps
 Polio
 Rubella
 HPV

10. Universal Immunization
Programme
 Largest UIP program in the world.
 Universal Immunization Programme launched in
India on November 19th, 1985. Originally known as
Expanded Programme on Immunization[EPI] (WHO
1974) to protect all children of the world against six
vaccine-preventable diseases (VPDs) - Tuberculosis,
Diphtheria, Tetanus, Pertussis, Polio and Measles
 Targets include 27 million infants and 30.2 million
pregnant women every year
 Two new vaccines (JE and Hepatitis B) introduced in
select areas

12. National Immunization Schedule (Jan.,
2011)
Age Vaccines
Pregnant Women TT (2 doses/Booster)
Birth BCG, OPV-O, Hep B
6 weeks DPT -1, OPV -1, Hep B
10 weeks DPT -2, OPV -2, Hep B
14 weeks DPT -3, OPV-3, Hep B
9 months Measles
16-24
months
DPT booster, OPV – Booster, MCV (Measles Containing
Vaccine), JE*
5 years DPT Booster 2
10 years TT
16 years TT

15. If a dose is missed……..
 Give the dose at the next opportunity
irrespective of the time gap
 Do not start the schedule all over again

16. Tetanus toxoid
 Intramuscular – upper arm – 0.5 ml
 Pregnancy – 2 doses - 1st dose as early as
possible and second dose after 4 weeks of
first dose and before 36 weeks of pregnancy
 Pregnancy – booster dose (before 36 weeks of
pregnancy) – If received 2 TT doses in a
pregnancy within last three years. Give TT to
woman in labour, if she has not received TT
previously
 TT booster for both boys and girls at 10 years
and 16 years
 No TT required between two doses in case of
injury

17. BCG
 At birth or as early as possible till one year of age
 0.1 ml (0.05ml until one month of age)
 Intra-dermal
 Left upper arm

18. Hepatitis B
 Birth dose – within 24 hours of birth
 0.5 ml
 Intramuscular
 Antero-lateral side of mid-thigh
 Rest three doses at 6 weeks, 10 weeks and 14
weeks

19. OPV
 Zero dose – within first 15 days of birth
 2 drops
 Oral
 First, second and third doses at 6, 10 and 14
weeks with DPT-1, 2 and 3
 OPV booster with DPT booster at 16-24 months

20. DPT
 Three primary doses at 6, 10 and 14 weeks with
OPV-1, 2 and 3
 0.5 ml
 Intra-muscular
 Antero-lateral side of mid-thigh
 One booster at 16-24 m with OPV booster
(antero-lateral side of mid-thigh) and second
booster at 5-6 years (upper arm)

21. Measles
 At 9 completed months to 12 months
 Give upto 5 years if not received at 9-12
months age
 Second dose at 16-24 months (select states
after catch-up campaign) – Measles
Containing Vaccine
 0.5 ml
 Sub-cutaneous
 Right upper arm
 Along with Vitamin A (1st dose) – 1ml (1 lakh
IU) - oral

22. Vitamin A
 1st dose – 1 ml (1 IU) - along-with Measles first
dose - Oral
 Subsequent 8 doses (2 ml or 2 lakh IU) every six
months till 5 years of age starting with DPT first
booster at 16-24 months
 Use only plastic spoon provided with Vitamin A
solution

23. Japanese Encephalitis
 SA 14-14-2 vaccine in select endemic districts
after campaign in UP, Bihar, Assam, Haryana,
Andhra Pradesh, Goa, Karnataka, Manipur, West
Bengal, Tamil Nadu
 16-24 months with DPT and OPV booster
 0.5 ml
 Subcutaneous
 Left upper arm

24. Vaccines and Cold Chain
 The cold chain is a
system of storing and
transport vaccines at
recommended
temperature from the
point of manufacture to
point of use

26. Vaccines
 Live attenuated – BCG, Measles and OPV
 Inactivated killed – DPT, TT, whole–cell pertussis,
hepatitis B
 All vaccines should be stored at plus 2 to plus 8
degrees ideally in Ice Lined Refrigerators/ Domestic
Refrigerators
 All government supply vaccines come with Vaccine
Vial Monitors (VVMs)
 BCG and Measles vaccines are in powder form and
come with diluents. Reconstitution is needed before
use.
 Use reconstituted BCG and Measles vaccines within
4 hours of reconstitution and JE within 2 hours of
reconstitution if kept at +2 to +8 degrees
 Use separate 5 ml syringes for each reconstitution

27. Cold
Why have the Cold Chain?
If vaccines are exposed to excessive
they may lose their potency or effectiveness.
Heat
Light

28. HEAT DAMAGE
Heat damage is cumulative effect
Reconstituted vaccine is most
sensitive to heat and light.
Measles and BCG vaccines should not
be used 4 hrs after reconstitution and
JE 2 hrs after reconstitution
Temperature of diluents & vaccine
must be same during reconstitution

29. Heat sensitivity
 BCG (after reconstitution)
 OPV
 Measles (before and after
reconstitution)
 DPT
 BCG (before reconstitution)
 DT
 TT
 HepB
LEAST SENSITIVE
MOST SENSITIVE

30. Sensitivity from Freezing
 HepB
 DPT
 DT
 TT
LEAST SENSITIVE
MOST SENSITIVE

31. Remember
 All vaccines tend to lose potency on exposure to
heat above +80 C
 Some vaccines (Hep B, TT, DPT) lose potency
when exposed to freezing temperatures
 Some vaccines are sensitive to light (BCG,
Measles).
 The damage is irreversible
 Physical appearance of the vaccine may remain
unchanged but potency might be lost.

32. Vaccine carriers
• Used for carrying vaccines (16-20
vials) and diluents from PHC to the
outreach session sites.
• With 4 conditioned icepacks
maintain inside temperature of 2-80C
for 12 hours.
• Close the lid of the carrier tightly.
• Never use any day carriers with 2
icepacks or thermos flask for
carrying vaccines.

33. Place four conditioned Ice-Packs
against the sides of the carrier
Place the plastic bag containing all
vaccines and diluents in the centre of
the carrier.
Fill the Ice-Pack with water to mark. Check
water level before every use. Do NOT add
salt to this water.
Fit the stopper and screw on the cap tightly
Make sure the Ice-Pack does not leak
Wipe the Ice-Pack dry and place in the
Deep Freezer
Prepare Ice-Packs for Freezing
Place frozen Ice-Packs in the open till they
“sweat,” (some condensation or droplets of water)
Check if an Ice-Pack has been conditioned by
shaking it and listening for water
Unconditioned Ice-Packs may damage freeze
sensitive vaccines (DPT, DT,TT and Hepatitis B)
Condition Frozen Ice-Packs
Pack the Vaccine Carrier
1 2
3
 Collect vaccines in the carrier on the session day
(Vaccine carriers may not store vaccines effectively
beyond 12 hrs)
 Do not drop or sit on the vaccine carrier.
 Do not leave in sunlight. Keep in shade.
 Do not leave the lid open once packed.
4 Remember to..
Correct Packing of the Vaccine Carrier

34. OPV
DPT
DPT
DPT
DPT
DT
DT
Diluent Diluent Diluent
TT TT TT
TT
DPT
Measles Measles
Measles
OPV
OPV OPV
Measles
Measles Measles
Measles
Measles Measles
OPV OPV
OPV
BCG BCG BCG
TT
DPT
DPT
DPT
Measles
DPT
Hep B
Hep B
DTT
DPT
DPT
DPT DPT DPT
DT
TT
BCG
BCG
BCG
TT TT TT
DT
DT
DT
Hep B Hep B
Hep B Hep B Hep B
BCG BCG
DPT Diluent
Diluent
Diluent
Diluent
Keep thermometer hanging
position in basket and maintain
temperature between
+2O C to +8O C (monitor morning
and evening)
Arrange vaccines in
order (top to
bottom)
Hep B
DPT, DT, TT
BCG
Measles
OPV
Follow Early Expiry
First Out (EEFO)
Discard any
frozen Hep B,
DPT, TT and
DT
Store all
vaccines in
baskets
Store diluents
in baskets, for
24 hours before
next session
Keep space
between
boxes
Storing vaccines in the Ice-Lined Refrigerator

35. Freezing Ice-packs in the Deep Freezer
Never store
UIP vaccines
in the DF.
Use only for
freezing
icepacks
Large compartment
Wipe dry and arrange
20-25 unfrozen icepacks
vertically (never flat) in a
crisscross pattern with
space for air circulation
Un-frozen
icepacks for
freezing
Store frozen
icepacks only
up to half the
height of the
large
compartment
Small compartment
Arrange and store
frozen icepacks
vertically, in layers.
Also store in cold
boxes

36. Domestic Refrigerators
 Only in urban areas with assured electric supply
 Hold over time (time taken in absence of power to
raise temperature from minimum i.e. +2 degrees
to maximum i.e. +8 degrees for an equipment) for
a domestic refrigerator is only four hours
 Specific order of storing ice packs and vaccines in
domestic refrigerator

37. Storing vaccines in Domestic
Refrigerator
 Ice packs and OPV in freezer
 Block door panels (where bottles are stored) and
vegetable tray at the bottom with thermocol
 Measles vaccine may be stored in the chiller tray
below the freezer followed by T – series vaccines
in the shelves below
 Hepatitis B should be stored below all vaccines

38. Usable and Unusable stages of
VVM

39. Safe vaccines and waste disposal

40. Safe Injections
 Cover any small cuts on the service provider’s skin.
 Wash or disinfect hands prior to preparing injection
material.
 Always use an Auto Disable Syringe (ADS) for each
injection and a new disposable syringe to reconstitute
each vial of BCG and measles
 Avoid giving injections if the skin of the recipient is
infected or compromised by local infection (such as a
skin lesion, cut, or weeping dermatitis)
 Check expiry date and VVM before use
 If the injection site is dirty, wash with clean water
 Use only diluent supplied with vaccine for reconstitution
 Write time of reconstitution on label - Use reconstituted
vaccines within 4 hours
 Use hub cutters immediately after injection has been
administered to separate needle from syringe
 Disinfect sharps and non-sharps before disposal

41. Simple ways to improve injection
safety
 Follow product-specific recommendations for use,
storage, and handling of a vaccine.
 Discard any needle that has touched any non-sterile
surface.
 Discard a syringe that has been punctured, torn or
damaged by exposure to moisture
 Consider all used equipment as contaminated
 Cut the used syringe at the hub immediately after use.
Practice safe disposal of all sharps
 Deposit used sharps (needles) in a hub cutter and
disinfect before safe disposal.
 Prevent needle-stick injuries. Do not recap or bend
needles.
 Anticipate sudden movement of child.

42. Adverse Events Following
Immunization (AEFI)

43. AEFIs
AEFI is any medical incident that takes
place after an immunization, causes
concern, and is believed to be caused
by immunization
AEFIs need to be detected, properly
managed clinically, reported,
investigated, monitored and promptly
responded to for corrective
interventions

44. AEFI…..types
 Vaccine reactions (high grade fever following
DPT) – caused/precipitated by active component
or one of the other components of vaccine such
as adjuvant/ preservative/ stabilizer
 Program error (bacterial abscess due to unsterile
injections) – caused by vaccine preparation,
handling or administration
 Injection reaction (fainting spell in teenager after
immunization) – caused by anxiety or pain from
injection rather than due to vaccine
 Coincidental (pneumonia after pulse polio NID
during winters) - event occurs after immunization
but is not caused by vaccine – chance temporal
association

45. Common minor vaccine reactions
 Local reaction (pain, swelling and/or redness), fever
and systemic symptoms (e.g. vomiting, diarrhea,
malaise) can result as a part of the immune
response.
 Local reactions and fever should be anticipated in
only 10% of the vaccine recipients, except in the
case of whole cell DPT which produces fever in
nearly half of those vaccinated.
 Fever and minor local and systemic reactions usually
occur within a day or two of immunization (except for
those produced by measles/MMR vaccine which
occurs 6 to 12 days after immunization) and only last
for few days.
 Fever and minor local reactions can usually be
treated symptomatically with paracetamol.

46. Rare Serious Adverse Events
Vaccine Reaction
BCG Suppurative adenitis, BCG Osteitis,
Disseminated BCG infection
Hib None known
Hep B Anaphylaxis
Measles/MMR Febrile Seizures, Thrombocytopaenia,
anaphylaxis
OPV Vaccine associated paralytic polio
Tetanus Brachial Neuritis, anaphylaxis, sterile abscess
DPT Persistent (>3 hrs) inconsolable crying, seizures,
hypotonic hypo-responsive episode,
anaphylaxis/shock
Japanese
Encephalitis
Serious allergic reaction, neurological event

47. Reporting of AEFIs
For Immediate Reporting and Investigation
 Death, hospitalization, disability or other serious and
unusual events that are thought by the public to be
related to immunization
 Anaphylaxis
 Toxic shock syndrome (TSS)
 Anaphylactoid (acute hypersensitivity) reaction
 Acute Flaccid Paralysis (AFP) - Any case of AFP will be
reported through the current system for AFP surveillance
and reporting
 Encephalopathy
 Sepsis
 Any event where vaccine quality is suspected
 Events occurring in a cluster

48. Reporting of AEFIs
 Report immediately by telephone/ fax/
messenger to PHC doctor/District
Immunization Officer or Chief Medical Officer
 First Information Report format for AEFI
reporting to be used
 Keep vaccines, diluents and syringes
(including that used for reconstitution) for
investigation
 Be vigilant for other cases
 Do not use multi dose vials further if AEFI
occurs. If available use single dose vials.

49. Single dose vs multi dose vials
 Single dose vaccines
are more costly
 Per dose cold chain
space occupied is more
 Less wastage of doses
if number of
beneficiaries are less
 Lesser chance of AEFIs
occurring due to
incorrect handling
 More immunization
waste generation
 Multi dose vaccines
cheaper
 Reduced per dose cold
chain space required
 Wastage is more if
number of beneficiaries
are less
 More chances of AEFI
(cluster) occurring due
to incorrect handling
 Less generation of
immunization waste

50. Desirable vaccines
• Pentavalent (DPT + HepB + Hib)
• Hib
•Typhoid
•Chickenpox

51. Hib vaccine
 Haemophilus influenzae b (pneumonia,
meningitis)
 0.5 ml
 Intramuscular at Antero-lateral side of mid-thigh
 At 6, 10 and 14 weeks and a subsequent booster
after age of one year (currently not included officially in
GOI’s Immunization Schedule)
 Combination with DPT + Hep B also available

52. Pentavalent vaccine
 DPT + Hep B + Haemophilus influenzae b
 Intramuscular
 Antero-lateral side of mid-thigh
 0.5 ml dose
 At 6, 10 and 14 weeks with booster at 16-24
months
 Proposed to be piloted in Kerala and Tamil Nadu – pending
ICMR study completion

53. Typhoid vaccine
 Salmonella typhi
 Vi polysaccharide vaccine
 0.5 ml dose
 Intramuscular or subcutaneous
 At two years of age (currently not included officially in
GOI’s Immunization Schedule)
 Revaccination every 3-4 years

54. Chickenpox vaccine
 Varicella vaccine
 Any time after 15 months (currently not included officially
in GOI’s Immunization Schedule)
 One dose if less than 13 years of age
 Two doses (gap of four to eight weeks) if more
than 13 years of age
 0.5 ml
 Subcutaneous
 Upper arm

55. i. Test for Sensitivity Reaction
ii. Adrenaline (1:1000 solution) to be kept ready.
iii. Properly sterilize equipment and apparatus.
iv. Measles and BCG vaccines to be reconstituted only
with diluents supplied by manufacturer.
v. Reconstituted Vaccines must NEVER be retained
for subsequent use.
vi. Don’t store anything else in the refrigerator other
than vaccines.
Precautions

56.  WHO set to declare India free of polio
 India hails polio-free 'milestone:
India is on course to be formally declared free of polio this year, marking a
milestone in global health.
The country's last case of the polio virus was detected on 13 January 2011 in a
two-year-old girl in West Bengal. Three years without any new cases means
India can be declared polio-free.
"We give huge credit to the government … It makes us extremely proud and
highly responsible for having helped the government to reach this incredible
achievement," India's World Health Organisation representative, Nata Menabde,
said
Recent Good News

57. THANK YOU